It’s always been unironically fascinating to me how primitive systems thinking is in healthcare. Frederick Taylor was a turn of the 19th century industrial engineer credited with the development of scientific management, known as Taylorism colloquially. Taylor’s main idea as described in his Principles of Scientific Management was to apply the scientific method and experimentation as a management tool to figure out what’s really going on inside the organization and what processes work best instead of relying on impulse, intuition, and habit. This on its own should not be controversial. Discord about Taylor arises from the way Taylorism has been applied in practice, through the meticulous measurement of employees in order to justify the creation of onerous compensation structures and unrealistic performance expectations. As Mr. Sullivan and Mr. Muller point out, this is increasingly a problem in healthcare through the rise of pay-for-performance measures and evidence-based medicine requirements that are detached from reality. Taylor himself is not entirely guilt-free of this association, as he did have a consulting business through which he showed a willingness to advise exactly this type of tyrannical measurement as long as it would sell his consulting product. Unfortunately villains in the real world are rarely straightforward. In addition to proposing the scientific method and measurement as management tools, Principes of Scientific Management also instructs managers to treat employees as human beings by considering employee capabilities and motivations when assigning work and for managers to be actively engaged in the training and development of their employees.

That being said, although Taylor was instrumental in introducing the scientific method to the practice of management, industrial engineering theory was already evolving beyond Taylorism and its flaws at the time of his death in 1915, and has made significant advances in both theory and practice since then. This is to say that Taylorism in industry has been out of fashion for 100 years already, so it’s both interesting and frustrating to see it so earnestly adopted in healthcare only now and in such a chimeric form. The work of W. Edwards Deming, Peter Drucker, Taiichi Ohno, and even Taylor’s contemporary Henry Ford made great strides to humanize and correct the errors of Taylorism. This work remains unknown and misunderstood in the healthcare field, but of course everybody must start somewhere.

However, although healthcare systems engineering is still in its nascent stage, there is little reason for optimism or hope for actual clinicians that the situation in general will change for the better, regardless of their attempts to fight this problem of tyrannical measurement. While industrial engineering advanced significantly beyond Taylorism, most of this knowledge is not being put in practice widely despite being around for quite some time. Bob Emiliani dives into the question of why this is the case in “The Triumph of Classical Management over Lean Management“. Mr. Muller is correct to point out that manager expertise is an issue, but this is only a symptom of the problem. Low level managers are less affected to do this problem insofar as they are directly engaged with the work, so even if they were not previously experienced or taught they are bound to learn quickly. The root of the problem lies in the scale of organizations and the implications that this has for increasingly higher levels of management. As you go up the levels of management, the managers are paradoxically vested with increasingly greater levels of resources while at the same time increasingly less knowledgeable of how to properly utilize those resources due to being more removed from the actual work. As the Russian proverb wisely says, God is high above and the Tsar is far away. This is compounded by the fact that high ranking management needs to justify its existence to their employees and the organizations funders (whether public or private), needs to manage conflict between different departments vying for the same resources, and has a perfectly human (surprisingly, managers appear to have limbic systems) need to minimize risk to the self from mistakes made downstream. Is it surprising then that the solution management uses to negotiate all these stresses are dumb, objective measurements that they can point to when something goes wrong? Downstream employees say they were following instructions to explain why a mistake is not their fault, upstream managers say they were following best practices.

This is all colorfully illustrated in Eli Goldratt’s “The Goal“, a delightful book that I highly recommend. It’s a cult hit among industrial engineers and operations consultants, butit’s also a good bridge for clinicians who have a visceral reaction to the specter of Cheesecake Factory management insofar it shows that their frustrations with administration are shared in other industries and explains what good scientific management can look like. The book itself is a novel and not especially well written, the characters are blunt and the events can feel conveniently orchestrated, but the plot moves along at a rapid pace making one always wonder what happens next. In many ways it reminded me of a Dan Brown novel. The story follows Alex Rogo, an industrial engineer who is the head manager of a struggling factory producing a variety of widgets. Alex is a humane character in that it’s obvious he cares deeply about his factory and the employees that work there, but he is also limited in his ability to be patient, to keep promises, and to fully understand his situation. These challenges extend to his personal life. Alex’s main challenge in the story is that he did everything that he was supposed to: he went to the right schools, got the right internships, and once he became manager made sure that his factory did well on all the metrics that the central corporate offices believe to be important. Why, then, is his factory failing? Why are his costs always increasing? Why are his orders always overdue? All this should be a familiar setting to healthcare professionals.

Without spoiling the novel itself, and leaving Alex’s adventure for you to discover for yourself, the main point of the book is that blind measurement is not only ineffectively, but actively harmful to organizations’ ability to achieve their eponymous Goal. Measurement has to be intelligent and strategic, designed to analyze and solve specific problems in the organization rather than be applied haphazardly trying to use the measurement to find problems to solve. For frontline practitioners the book implies two key pieces of advice. The first is that although the Tsar is far away and measuring foolishly, this does not mean that you can’t use measurement appropriately within your local context to help you solve problems that you as a person immediately affected by these problems, the person with that dasein to use Heidegger’s term, are facing. The second piece of advice is to stop trying to convince whoever is making you do ineffective measurement to change, because the odds are that they are incompetent and won’t change until proven wrong. To that effect, rather than asking for permission, the frontline practitioner needs to take the initiative (and responsibility) to make the necessary change and then let the results speak for themselves.

I recommend reading Mrs. Muller, Emiliani, and Goldratt’s books for the rest.

Dr. Jerome Groopman is the Chair of Medicine at the Harvard Medical School and staff writer for the New Yorker. His 2007 book How Doctors Think seeks to inform lay readers through a collection of medical case studies about the training that physician receive and the thought process through which they gather information and formulate the diagnosis. Most importantly, however, the book emphasizes the cases in which the logical process through which the diagnosis is developed fails and the physician misdiagnoses the patient and puts their life in danger. Sometimes the diagnostic process repeatedly fails to correctly identify a condition across multiple physicians. How Doctors Think begins by presenting the case of Anne Dodge who had been misdiagnosed for fifteen years by psychiatrists, internists and dietitians as suffering from bulimia and irritable bowel syndrome until a gastroenterologist finally identified celiac disease as the cause of her weight loss. Dr. Groopman also recounts how three renowned Boston-area surgeons had misdiagnosed the hand pain he was experiencing, including one diagnosis that was not a real medical condition (pg. 170). Diagnostic errors like these provide a stark contrast to the idealistic public image of physicians as precise and evidence based practitioners.

The book argues that most of these errors are not due to malice or incompetence, but are a natural byproduct of the mental heuristics that physicians must use to treat patients in a timely and efficient manner. Although physicians are trained in medical schools to carefully record the patient’s narrative and consider all possible options, the operational realities of the healthcare environment such as time-consuming electronic medical records and decreasing appointment durations force physicians to increasingly rely on shortcuts that are vulnerable to cognitive errors.

Dr. Groopman concludes by urging patients to participate more in the diagnostic process by asking physicians key questions such as “Are there any other possible causes?” and “Does any of the evidence not match the diagnosis?” The purpose of these questions is to force the physician out of their diagnostic autopilot mode and give them a chance to recognize any logical fallacies they may have committed. This collaboration would ideally improve physician decision making, decrease the frequency of medical errors, and improve patient outcomes.

Implications

The transition of payment systems from fee-for-service to pay-for-performance through programs like DSRIP and MACRA will inevitably put pressure on providers to standardize processes in order to reduce variability and improve population health outcomes. How Doctors Think reveals the significant variability that exists in physician decision making caused by individual practice preferences and errors during diagnosis, which is a major challenge for large healthcare organizations trying to meet their performance targets. Because “as many as 15 percent of all diagnoses are inaccurate” (p.24), organizations that can control and reduce this variability will be increasingly rewarded by programs such as DSRIP for standardizing their care. Safety net hospital are more vulnerable to such variation because they are more likely to face the resource constraints that force physicians to reduce their time with patients, which Dr. Groopman identifies as a major cause of diagnostic error. Fortunately analyzing the types of errors that physicians make provides a framework to understand how physician processes need to be adjusted and what changes can be made in the organization to reduce the occurrence of these errors. It is therefore recommended that all providers, but especially safety net hospitals, address the problems presented in How Doctors Think by implementing three operational reforms: communication standardization, diagnosis standardization, and treatment standardization.

Communication Standardization

Dr. Groopman emphasizes that good medicine relies on effective communication between the patient and physician. This requires the standardization of physician’s communication practices to ensure that they are obtaining as much information as possible from the patient.

Physicians should be trained to ask open-ended questions when interviewing patients, which avoids leading the patient towards a diagnosis that the physician is already thinking of, and “maximizes the opportunity for a doctor to hear new information” (p.18). The physicians should also be able to interview the patients quietly and uninterrupted, as distractions can cause the physician to miss important information (pg. 75). When the patient makes a statement that conflicts with the physician’s clinical judgement, the physician should make an effort to not dismiss the patient (pg.264). To maximize trust, the physicians must explain the condition and its risks in a clear manner, but also be prepared to spend more time with the patient when it is clear to the physician that the patient is still nervous or uncertain (pg. 88). Accordingly, the hospital should make it easy for physicians to extend their time with the patient or to schedule a follow-up appointment. Physicians should also explain why they are performing any tests and specifically what they are looking for (pg. 172) to engage the patient and give them a chance to express their own opinions and concerns. Finally, the physician needs to clearly explain all possible outcomes, the positive and negative features associated with those outcomes, and the likelihood of those outcomes (pg. 173) to enable patients to make the choices most consistent with their preferences. This discussion should always be framed within the context of the condition to minimize the risk of patients fearing the treatment’s side-effects more than the disease itself (pg. 246).

Diagnosis Standardization

Safety net hospitals should implement a diagnostic checklist that physicians must review at the end of each case to ensure that they are not committing a logical fallacy in their diagnosis. Common errors that physicians make include:

To avoid these logical failures, after the physician decides on a diagnosis they should be required to go through the following questions that Dr. Groopman recommends in the epilogue of How Doctors Think:

What else could it be?

Is there anything that doesn’t fit?

Is it possible there’s more than one problem?

What is the patient worried about?

Review the patient’s story from the beginning.

In addition, patients should be encouraged to ask these questions and should be trained to do so through informational materials available to them in waiting areas and posters around the hospital. The benefit of this strategy is that it engages the patient in their health and prevents the physician from ignoring the checklist by going through it carelessly to save time.

Finally, this diagnosis verification process can be further enhanced by implementing systems of physician peer monitoring, such as radiologists reviewing a sample of each other’s slides and discussing the diagnoses that are found to be incorrect (pg. 188). This allows physicians to identify mistakes in a safe environment and collectively improve their skills. The knowledge that they are being peer reviewed also encourages physicians to more careful in their decision making.

Treatment Standardization

Treatment protocols should be standardized across physicians practicing in safety net hospitals to reduce variation and ensure equity in the treatment that patients receive. Dr. Groopman highlights how two very different procedures can be believed to be the optimal treatment protocol at the same time simply because they are both championed by a prominent physician who “did it that way” (pg. 163). Physicians are also susceptible to influence from the industry to prefer treatment plans based on non-clinical incentives that may not put the patient’s interests at the forefront, which may be the case with spinal fusion surgeries (pg. 228). As much as possible, treatment protocols should be directly based on the available clinical evidence and physicians practicing at the safety net hospital should be expected to conform to them. This has the benefits of reducing variability, increasing the rate of physicians’ expertise gain, increasing NYC Health + Hospital’s ability to negotiate with insurers, and makes it easier to explain and justify treatment plans to patients.

Conclusion

Although How Doctors Think was published in 2007, experience with the healthcare system today quickly reveals that few of the lessons this book contains have been addressed. In fact, many providers have made the situation worse by continuing to put physicians under time-pressure without developing the physician workflows necessary to maximize patient-physician interactions or redesigning organizational processes to improve diagnostic quality. This fundamental gap in understanding between management and physicians demonstrates why How Doctors Think should be required reading for healthcare administrators.

With a 35,000 primary care physician shortage coming up in 2025, eventually the healthcare policy agenda is going to shift back to the medical education pipeline. In my previous piece on the Iranian healthcare system, I predicted that community health workers were a political dead-end because of the labor market lockout that the AMA has on the healthcare industry. I still predict that’s going to be true, which means that the conversation is instead going to focus on training physicians more efficiently. Fortunately, there’s already work being done on this front.

NYU SoM’s annual report highlights (NYU Three Year Pathway) the three-year medical program that the school launched in 2013. Back then the primary goal of the compressed schedule was to lower the overall cost of medical education and differentiate NYU SoM from the rest of the competition in the medical school marketplace, but the efficiency gains due to reduction in training must not be ignored.

The first batch of students in the compressed program are now graduating, with 15 out of 16 in the inaugural class successfully completing the degree. In addition, testing of the students shows the three year students demonstrating better knowledge and clinical skills than four year students at the end of their respective programs. This finding has enormous potential ramifications and requires additional research. Was the first three year class special, with top performing students self-selecting into the more ambitious program? I’d like to see a comparison of the three year program graduates against other program applicants who were rejected from the three year program due to space limitations and enrolled into the four year program instead. In addition, the three year students may be performing better because they’ve simply had one year less to forget everything that they crammed in MS1; it would be interesting to compare the clinical skills and knowledge of the three year graduates against their four year conterfactuals after they’ve been practicing medicine for a decade to determine which method is really better at integrating the knowledge for long term use. In the meantime, however, the three year program appears to be winning.

What’s important about the accelerated program is that it’s still not fully optimized. The majority of the program time savings is done through cutting down on the time dedicated to electives and residency interview. This is possible because the three year applicants are admitted with a guaranteed residency slot. However, the students in the three year program retain the option of switching back into the four year program,m which means that the core curriculum is still over-training physician to be able to go to any residency. The core curriculum can therefore be collapsed even further to focus only topics and rotations relevant to primary care. I would be shocked if such a degree can’t be reduced to a two year program. Could we produce a family physician in one year? Probably not. But a two year program would be a 100% efficiency gain.

Not to mention that being able to filter out primary care physicians out of the same pipeline that needs to train academic researchers and neurosurgeons would allow institutions to price the degree more appropriately, therefore further reducing the cost barrier of entry. The specialization could also allow institutions to relax their requirements for acceptance. Could we then get away with accepting people with high school degrees into this specialized primary care program, therefore collapsing the current 8 year primary care physician pipeline into a 2 year one? I don’t see why not. There’s no reason to require a Bachelor’s degree; practicing clinicians don’t use what they learn for their premed coursework and MCAT. Students in Europe start medical school straight out of high school and our kids aren’t any dumber.

The efficiency gains are enormous, but we’ll need to do the work to achieve them.

The organization and effectiveness of the rural primary health care reforms in Iran, focusing on the behvarz health workers and health homes, are reviewed and the potential for implementation in the Mississippi delta is analyzed. The analysis indicates that Iranian health houses are effective and clinically relevant to the health challenges faced by communities in Mississippi. These strategies however are not immediately replicable due to political barriers. Recommendation are to develop health worker training curricula in preparation for a political event that removes these barriers.

Background

In 1979 the Islamic Republic of Iran inherited from the Shah regime a dysfunctional rural health care system created by years of neglect. The rural maternal mortality ratio was 370 per 100,000 live births and the rural infant mortality rate was 120 per 1000 live birthsi. In addition, the rural physician to population ratio was only 1:18000.ii The new government, however, was determined to fulfill the promises of the revolution to its rural supporters, and as part of the Reconstruction Jihad decided on the creation of a network of health houses staffed by minimally trained local health workers. Physicians criticized this as a collapse in the quality of care,iii but the government arrested hundreds of them in response and moved forward with their plans.

Organization

Thirty years after the revolution, these plans have grown into a network of 17,000 rural health houses staffed by 30,000 salaried behvarz (community health workers) that provide primary care services to 23 million Iranians, or 95% of the rural population.iv Each health house is generally staffed by 1 male and 1 female behvarz, who are responsible on average for 1500 people in their village and surrounding communities.v The behvarz is required to have 11 years of education and be elected by their community before receiving 2 years of community health worker education at a district training center. The community selection is an intentional policy design meant to increase community engagement, ensure cultural competence and decrease personnel turnover. Behvarzduties include collecting census information, maintaining family health records, maternal and child care, family planning, immunization, home visits, simple curative care, administration of medicines, and sanitation.vivii As the first point of contact, they are also responsible for basic triage and referring cases to one of 2300 primary care clinics at the district level, who provide ambulatory care for approximately 10,000 people.viii In addition to treating patients sent directly to them at the clinics by the behvarz, primary care physicians make intermittent rounds through the villages their clinic is responsible for. Any cases that can’t be handled at the district primary care clinics are referred to secondary care at district hospitals or tertiary care at provincial hospitals.

Access to primary care services in public facilities is free and is financed through federal budget transfers.ix In 1995 the Medical Services Insurance Organization funded by a general tax was created to provide insurance to civil servants, self-employed and special groups. In 2005 the Rural Health Insurance Program (RHIP) expanded this coverage to all rural citizens, which resulted in 95% rural insurance coverage.x Notably, RHIP also formalized the family practice (FP) specialty in an attempt to improve quality of rural care. This has resulted in friction with the behvarz system, as there is some evidence that FPs don’t always provide superior care.xi

Achievements

Twenty years of primary care reform in Iran resulted in significant advancements, including reduction of the fertility rate from 6.5 to 1.92, reduction of the rural infant mortality rate from 71 per 1000 live births to 30.2 per 1000 live births, reduction of rural maternal mortality ratio from 370 per 100,000 live births to 35 per 100,000 live births, and achievement of over 96% immunization coverage for DPT, MMR and Polio vaccinesxii. Most importantly, there was significant convergence with the urban infant mortality rate and maternal mortality ratio, which during this period had improved to 27.7 per 1000 live births and 22.0 per 100,000 live births respectively. By 2015 the expansion of the family practice specialty under RHIP further reduced the overall infant mortality rate to 13 per 1000 live births and the maternal mortality ratio to 25 per 100,000 live birthsxiiixiv. Avoidable death rates for rural and urban areas have also converged (37.40% and 36% respectively.xv In some critical measures the reforms have even enabled rural communities to surpass urban ones. Rural hypertension and diabetes prevalence, 17.2% and 5.6% respectively, are lower than in urban communities, where they are 18.4% and 8.5% respectively.xvi

Comparison to Mississppi

Mississippi is chosen for comparison with Iran because the state was rated as the worst health system in the U.S. eight years in a rowxvii and a pilot program at Jackson State University is experimenting with Iranian-style health homes.xviii In 2012 the maternal mortality rate in Mississippi was 39.7 per 100,000xix, and in 2014 the infant mortality rate was 8.2 per 1,000 live births, ranking last in the U.S.xx Full immunization at age 2 was only 80.5% in 2007. Also, 67.8% of Mississippi adults were obesexxi, 11.6% were diagnosed with diabetesxxii and 22.7% smoked in 2009.xxiii Prevention and treatment is complicated by the greatest physician shortage in the U.S.xxiv (159 physicians per 100,000) and only 82% of the population having insurance coverage.xxv

Lessons for U.S. Policy

Mississippi’s challenges are similar to those faced by Iran and make the behvarz model a valuable source of lessons in healthcare system design due to Iran’s superior performance on many of these metrics when compared to Mississippi. The success of the behvarz reveals two key lessons for future primary care reforms in the state. The first is that dedicating funding to primary care and public health results in significant health gains for the population. However, this is not a new idea and has been argued for decades by public health officials. The population health successes of the Family Health Program in Brazil are another current example of this policy. The most important lesson, and the point where the Iranian behvarz differentiate themselves from the Family Health Program, is that the program is primarily administrated by non-physicians. Iran reveals that it is possible to create significant improvements in basic primary care access and corresponding health outcomes with limited physician involvement. This has important implications for health system capacity building in rural areas and developing countries, a key U.N. goal after the recent ebola outbreak. Delegating basic and routine primary care tasks to minimally trained behvarz allows for highly trained physicians’ time to be allocated to more serious cases. In addition to the efficiency gains, physicians are likely to have improved job satisfaction due to decreased stress on their time and more meaningful utilization of their unique skills. The more efficient skill mix in the healthcare system could also allow for lower total healthcare expenditures.

However, the political environment in the U.S. is currently poorly aligned to implement this model. The behvarz reforms were a conscious top-down commitment by the Iranian government to a primary care based health care system. In the U.S., on the other hand, Congress only committed $1billion per year to the Prevention and Public Health Fund – far short of the $12 billion per year level recommended by the Institute of Medicinexxvi. In addition, only 30% of Iranian government revenue is from taxation and 70% is derived from the sale of natural resources.xxvii This makes Iran’s generous primary health care transfers difficult to replicate. Finally, Iran was able to bypass the protests of the medical community against the behvarz through authoritarian oppression. This is not an option in the U.S. and the physician community is likely to lobby against behvarz as they do against nurse practitioners.xxviii In general the separation of powers in the American political system is designed to empower such opposition. In fact, this may even be happening in Iran, where the 2015 reform expanded FP and specialist financing, but did little for the behvarz.xxix

Facing these realities, the recommendation for policymakers in the U.S. is to prepare for a future political crisis that could be used as an opportunity to implement health homes by developing health worker certification curricula that could be quickly adopted.

[xv] The Kaiser Family Foundation, statehealthfacts.org. Data source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau’s March 2009 and 2010 Current Population Survey (CPS: Annual Social and Economic Supplements) , at http://www.statehealthfacts.org/profileind. jsp?cat=3&sub=39&rgn=26.